A LETTER FROM PARIS

THE LAST TWO SEASONSl brought important innovations in the theatrical life of Paris. Bold accomplishments attracted attention in the realm of staging as well as in that of dramatic literature,at the same time as the structure and activity of the national theatres were modified by the new political regime. The Opera, the ComMie Fran9aise and the Odeon have in fact seen the beginning of a new stage in their long history. The direction of the Opera was entrusted to A. M. Julien, who had succeeded brilliantly as organizer of the International Paris Festival, then of the Theatre des Nations, where he had given an important place to operatic performances. Carmen, which had only been performed at the Opera Comique, was staged with great plastic richness and precision by Raymond Rouleau. Hundreds of "supers," as well as live horses, mules and monkeys move about the immense stage of the Opera. The ComMie Fran9aise has undergone a crisis involving many vicissitudes which have roused a great deal of comment in the press. The Minister of Cultural Affairs, M. Andre Malraux, appointed as new Administrator a diplomat, ~L de Boisanger. He also decided to take from the Comedie Fran9aise its second house, the Salle Luxembourg, formerly the Odeon, in order to make of it a separate theatre, called the Theatre de France and entrusted to the direction of Jean-Louis Barrault. Last of all, he increased the authority of the Administrator named by the government, reducing the powers of the Committee representing the societaires (actor-shareholders); as a matter of fact, these latter have, since 1680, formed a society which by itself administers a theatrical enterprise which receives financial aid from the State. This new orientation naturally prov9ked discontent among the actors. The most regrettable consequence was the resignation of Jean Meyer, who, by his activity and his talent as director, had for many years dominated the productions of the Comedie Fran9aise. Finally, early in 1960, for reasons which are not clearly understood, M. Malraux revoked the powers of M. Boisanger, who had been the executant of his policy. The latter has appealed to the Council of State against a


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A LETTER FROM PARIS. E DITORS Medical Examiner: r As the result of the last concours of agregation in medicine, MM. Dieulafoy, Grancher, Lionville, Le pine, and Legroux have become agreges of the Faculty of Paris, and MM. Grasset and Balestre of the Faculty of Montpellier. The term agrege conveys the meaning of " fel low," or, as used with us, might, per haps, be better translated as assistant professor.
From the agreges are elected the professors, as vacancies occur in the Faculty.
The road to this position is by no means an easy one to travel, and this system of competitive examinations is one that the profession in France is justly proud of. The concours is open to any graduate of the French school who has reached the age of twenty-five years. For the nine va cancies of this last concours there were twenty candidates.
The first trial was an essay upon Anatomy and General Physiology, and the subject given was " On the Lymphatic System." This had to be treated without notes or aid of books for reference, and each candidate read his essay before the committee of the Faculty, in the large amphitheatre of the school, which of course was open to the public.
The second examination consisted in a lecture of three-quarters of an hour on some given medical question, three hours being granted for prepa ration, but without aid of books or notes. The jury then having exam ined the printed works of each candi date, the opening trial was finished and two of the competitors were eliminated.
Then commenced the final trials (epreuves definatives). The first was a public lecture of an hour, on a sub ject of general pathology given by the jury twenty-four hours previously. The second consisted in a public clinical lecture on some case, desig nated by the jury, in the hospital wards (Hotel Dieu or Pitie), after fif teen minutes' examination by the can didate. The third and last trial was the writing of a thesis (subject given by the jury), which had to be printed in regulation form seventeen days after the subject was announced.
From this summary of the require ments of the concours of agregation, it will be seen that it is no easy matter to acquire the title of agrege, and that there is no "royal " road to that posi tion.
Although the concours was opened in December, the theses were not finished until April. As all the examinations were public, they were followed very closely, not only by the students but by the graduates of the school, for there is always an interest felt in these contests by the profession at large, and there are few things connected with the school in which the French take more pride than in these struggles for position. There is no chance for favoritism in the ex aminations, as their publicity forbids any underhand work. One curious part of the concours is the " quizzing " of one candidate by the others. It is upon the thesis. The candidate seats himself in the "pulpit" of the large amphitheatre, thesis in hand ; while, seated at a table in front of him, are the members of the jury, attired in their red silk gowns and hats, and two of the competitors, likewise supplied with copies of the thesis. The latter successively ply the " man in the pulpit " with questions on the subject of his thesis, trying to break down any theory that he may have advanced, or to catch him upon some point that he may not have considered. The one who questions is incited, perhaps, by the thought that he soon will un dergo the same process, or, indeed, he may be smarting under the remem brance of questions that were given to embarrass him in the presence of eight or nine hundred auditors. With that characteristic French style, the questioner generally commences with a few remarks upon the pleasure he has had in reading the essay before him, and congratulates the author upon its merit, and then he suddenly launches out upon some hidden ques tion that does not always betray the amount of good feeling one would expect after his prorogation. The author of the thesis commences his reply by thanking the other for his congratulations, perhaps expressing himself as highly honored by such a compliment from so distinguished a confrere, and then replies to the ques tions asked, referring, it may be, to another page of his thesis where the answer may be found, or, perhaps, giving some new references to prove his position. Thus it goes on, and the jury and public sit and listen, generally amused at the contest that is going on before them. One can judge that under these circumstances a man's ability has a clear chance of making itself evident, although there is in such trials, perhaps, a tendency to the cultivation of egotism, which may in some measure account for peculiarities of to-day.
The report of M. Chauffard, presi dent of the jury, to the Minister of Public Instruction, mentions this con cours as the most satisfactory that has been held for many years, and pays high compliments to those who were not elected as well as to the successful ones. The subjects for the theses are chosen by the Faculty with reference to those questions that are considered as needing more research, and we find the pathology of the nervous system occupying a prominent position among the subjects given.
Five subjects were on questions of special and gen eral therapeutics. This last choice was not amiss, for therapeutics are not too closely investigated here. Even the writer in the half-official Gazette des Hopitaux admits this, for in this connection we find the follow ing rather pointed inquiry : " Does the Faculty commence to understand that therapeutics is the feeble side of its teaching, and that, without losing anything for the future in its useful instruction on pathological anatomy and pathogeny, it is time to direct its studies a little toward that which is the object and goal of all medical re searches ?" This is rather a broad hint, but unfortunately embodies too much truth in indicating a very weak point in French medical training. To for get the patient in studying his disease is, to speak mildly, rather an awkward thing for the patient.
Dr. Siredey has published an article in the March and April numbers of the Annates de Gynecologie, which is entitled: "Puerperal Fever does not Exist." He holds that under the name of puerperal fever are con founded many different diseases, each having a proper train of symptoms, a special course, and a variable prog nosis, and that among them it is pos sible to make a differential diagnosis. The numerous and varied opinions that are held upon this question he ascribes to the variety of lesions that have been found upon post-mortem examination. For some persons the metritis embodies the principal lesion, while for others a peritonitis, phlebitis, or lymphangitis has the preference. The essentialists object that the dis ease cannot be named from any of the lesions, as these vary with the case, with the epidemic, or indeed may be altogether wanting. Dr. Siredey con tests this last view that there may be no lesion, and holds that the autop sies were not made with sufficient care, and are too few to be of value. In support of this opinion he mentions several cases in which, though at first nothing abnormal was found, a more careful examination demonstrated the presence of pus. From the vast number of cases exam ined where lesions were found, and from the few and doubtful records to the contrary, he deems it just to admit that the fever is not essential. Never theless, the name " puerperal fever " is preserved, and the various lesions in different parts of the body are con sidered as only secondary manifesta tions of this one disease. It matters little whether the action turns itself upon the uterus, the peritoneum, the veins, or the lymphatics; for the up holders of this idea, it is sufficient to know the eetiological conditions of the disease to be sure of its nature. So constituted, puerperal fever has been accepted by the most eminent. Depaul, P. Dubois, and Danyau, in the discussion of 1858, defended it. Trousseau, at first doubting, finally admitted it, not only in women, but in infants, and, indeed, in wounded men, provided they were placed near an obstetrical service ! In spite of his respect for such eminent authori ties, Dr. Siredey believes that in re taining the name " puerperal fever " we only perpetuate an error, and ob scure a question that it is of the highest importance to clear up. In fevers we find certain lesions that are constant. For example, in typhoid fever there is the ulceration of Peyer's patches, in scarlet fever the serous membranes are attacked, and the mu cous in measles. For the different lesions that are found after death from the disease called puerperal fever, Dr. Siredey thinks he is able to point out a series of symptoms that will show that several distinct diseases have been confounded heretofore, and that a differential diagnosis can be made among them. After mentioning the peritonitis, with its typhoid state and fetid diarrhoea and lochia, he treats of the really difficult, and for many impossible, diagnosis between phlebitis and lymphangitis. He com mences by endeavoring to show that many times the lesions considered to be in the veins were in the lymphatics of the uterus. The principal trunks of the lymphatics occupy the angles and sides of the uterus, and some times they acquire a volume of 5, 6, or 8 millimetres, equaling that of the veins, and hence liable to be con founded with them. The large circu lar vessel, situated at the juncture of the neck and body of the uterus, which is so often found filled with pus, is not a vein, but a lymphatic. Dr. Siredey thinks that many mistakes have been made from these anatomical peculiarities, and considers that in flammation of the lymphatics is the more common. Noting the very inti mate connection of the lymphatics with the peritoneum, and the frequent occurrence of peritonitis in the fever of child-bed, he argues that the socalled puerperal fever is generally but a lymphangitis. The differential diag nosis between this disease and phle bitis he places as follows : Chill-In the lymphangitis it is unique, and only appears at the commencement of the disease, while in phlebitis it is multi ple, and not only is found at the be ginning but at all periods of the dis ease. The chill of the lymphangitis appears in general from the first to the fifth day after the labor, while in an inflammation of the veins it occurs but rarely before the sixth day, and frequently much later. The temper ature reaches a high figure (40° to 410 C.) in the lymphangitis, but remains at this level, varying only by some tenths of a degree. In the phlebitis the temperature rises progressively, reach ing its maximum during the febrile paroxysm; then falls to rise again, presenting between the remissions and exacerbations a difference of several degrees. The pain is more intense in the abdomen for the lymphangitis, which may be accounted for by the peritonitis. The phlebitis does not give rise to intense abdominal symp toms. but reveals its existence by varied lesions that testify to the inva sion of the economy by pyaemia. The course of disease is much more rapid in the lymphangitis. Death oc curs generally eight or ten days after the labor, and in rare cases, in two or three days, while the phlebitis may extend from two to three weeks. Dr. Siredey admits that lesions of both diseases are found in some cases, but states that the symptoms show the first period belongs to the lymphangitis, while the second period is that of phlebitis. He illustrates his argument by giving in detail the history of four cases.
During the past two weeks the Paris journals, medical and secular, have been very much occupied with the voyage of the balloon Zenith. Messrs. Croce-Spinelli, Sivel and Tissandier made the ascent on the 15 th of April, and gained the height of 8,600 metres, but unfortunately the two former died during their exposure in this rarefied atmosphere, and Tissandier alone re mained to tell of their experience. The ballon was equipped with all the inventions that science has shown to be of use in such voyages, and each person was provided with a bag of oxygen by means of which he could supply himself with that gas when the quantity in the air should become too limited. However, these precautions seem to have been of but little service. Tissandier states that at twenty min utes after one o'clock (two hours after they left the earth) he saw the needle of the barometer pass 280 millimetres, and he tried to say "We are at 8,000 metres," but was unable to speak. The balloon then descended a short dis tance, but soon mounted again, and all three lost consciousness. When Tissandier came to himself, he found the balloon falling with frightful ve locity and his two companions dead. Self-registering tubes had been placed in the balloon to note the atmospheric pressure, and, though the majority of them were broken, two indicated that the maximum height reached must have been 8,600 metres. The ques tion that greatly interests the scien tific world is concerning the cause of the death of Croce-Spinelli and Sivel. Experiments have frequently been made in Paris by means of an air tight chamber, in which the pressure of the atmosphere can be reduced as desired. Under these conditions, M. Bert has been able, by inhaling oxy gen, to support a diminution corre sponding to an ascent of 8,900 metres. But unfortunately the conditions of the experiment and of an ascent have not been placed on exactly the same level. The subject is at present under consideration at the Academy of Med icine, but the opinion, as found in the medical journals, seems to be that the death was the result of an asphyxia from privation of oxygen, with the added influence of excessive cold; and, secondary to this, to pulmonary lesions such as accompany the as phyxia from carbonic acid. It is thought that the voyagers were not sufficiently careful in supplying them selves with the oxygen, or that the rapidity of the ascent prevented them from using the gas. One result of this balloon trip is an outcry against researches in such high regions, and the Academy finds itself called upon to discourage any future attempts by not offering inducements for the vent ure. Of course the wide-spread in terest in this fatal attempt has incited all those with a "ballooning" turn of mind, and already we hear of new ascents that are to take place.
It is generally admitted that Paris leads the world for fashion, and I i doubt not there is a great deal of truth in such an assertion. More particu larly was I convinced of this when I heard the following fashionable indi cation for the early use of the forceps : When a public singer is brought to the pangs of child-bed, one must use the forceps as soon as possible, lest the continued screaming of the woman should injure her voice. C. C. M. ' Paris, May 3d, 1875.
Chloral in Tetanus. -In the treatment of traumatic tetanus by chloral, Dr. Gontier reaches the fol lowing conclusions : Chloral may render great service in the treatment of chronic or subacute tetanus, and is especially preferable to other drugs. It is completely inefficacious in acute tetanus, and only has a slight palliative action.
It may be advantageously associated with tonics, diffusible stim ulants, and diaphoretics. Intravenous injections of chloral are extremely dangerous, and should, in the present state of science, be reserved for ex ceptional cases only. -Phil. Med. Reporter.
The Duration of Life.-The fol lowing facts on the duration of life appear in the Deutsche Versicherungs Zeitung : " In ancient Rome, during the pe riod between the years 200 and 300 a. d., the average duration of life among the upper classes was 30 years. In the present century, among the 1 same classes of people, it amounts to 50 years. In the sixteenth century the mean duration of life in Geneva was 21.21 years; between'1814 and 1833 it was 40.68 years; and at the present time as many people live to 70 years of age as 300 years ago lived to the age of 43."-Ibid.